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THE  FACTORS  ESSENTIAL  TO  COMPLETE  MEDI- 
CAL DIAGNOSIS. 

By  W.  S.  CHRISTOPHER,  M.  D. 

PROFESSOR  OF  DISEASES  OF  CHILDREN,  CHICAGO  POLICLINIC;  PROFESSOR  OF  PEDIATRICS 
COLLEGE  OF  PHYSICIANS  AND  SURGEONS,  CHICAGO. 

As  the  study  of  the  infecting  agents  has  progressed,  it  has  be- 
come more  and  more  apparent  that  diagnosis  to  be  of  the  highest 
clinical  value  should  be  expressed  as  accurately  as  possible  in 
terms  of  causation. 

While  an  exact  classification  of  cases  along  etiological  lines 
cannot  always  be  made  in  the  present  state  of  our  information  and 
with  our  present  methods  of  clinical  examination,  yet  so  much  can 
be  done  as  to  materially  improve  our  conception  of  individual  cases 
and  to  assist  our  management.  The  old  diagnosis  of  dropsy  was 
good  enough  until  the  causes  of  the  condition  were  discovered, 
when  it  became  a mere  symptom.  The  fact  that  the  causes  of 
dropsy  were  themsleves  mainly  anatomical  conditions,  the  results 
of  precedent  causes,  did  not  detract  from  their  value,  and  the  diag- 
nosis of  these  causes  materially  facilitated  the  study  of  the  cases 

presenting  thesymptom.  In  other  words,  the  tendency  has  been  to 

express  diagnoses  at  first  in  prominent  symptoms,  then  in  terms 
of  proximate  causes,  and  later  in  terms  of  causation,  less  and  less 
proximate.  But  the  more  remotely  from  the  symptom  the  ef- 
fective cause  is  traced,  the  more  numerous  become  the  discerni- 
ble relations  of  that  cause,  and  consequently  the  more  complex 
does  the  total  determinable  etiology  of  a given  condition  become. 
Diagnosis,  expressed  exclusively  in  anatomical  terms,  although 
sufficient  a dozen  years  ago,  is  no  longer  sufficient..  This  prop- 
osition is  generally  true,  because  the  anatomical  diagnosis  is  of 
no  higher  order  than  the  naming  of  a symptom,  even  although 
that  symptom  be  at  times  of  the  highest  significance  as  to  prog- 
nosis and  treatment,  and  even  although  in  many  instances  no 
diagnosis  less  proximate  can  be  made,  owing  to  the  inability  to 
secure  the  necessary  data.  Exceptions  to  the  proposition  occur, 

] 


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but  are  more  apparent  than  real.  Notable  instances  may  be  cited 
in  empyema  and  appendicitis.  In  both  of  these  instances  the 
anatomical  condition  per  se  threatens  life  and  may  be  directly 
remedied  and  the  danger  averted.  Practically  for  the  individual 
the  anatomical  diagnosis  is  here  sufficient.  But  surely  it  will 
not  be  contended  that  a diagnosis  of  causation  even  here  would 
be  valueless  even  if  only  for  its  use  in  diagnosis  and  prophylaxis 
in  others.  On  the  other  hand,  the  insufficiencies  of  an  anatomi- 
cal diagnosis  are  matters  of  daily  observation.  Probably  no- 
where can  this  better  be  shown  than  in  cases  presenting  the 
symptom  bronchitis.  This  symptom  occurs  as  a common  mani- 
festation of  many  acute  infections,  notably  the  exanthemata;  it  is 
sometimes  the  expression  of  a stercoremia;  very  commonly  it  is 
produced  by  autotoxemias.  Moreover,  underlying  backgrounds, 
especially  rickets  in  infancy,  are  responsible  for  its  maintenance 
and  often  must  be  modified  before  the  leading  symptom  can  be 
controlled.  The  recognition  of  this  varied  etiology  is  not  only 
necessary  to  the  best  and  most  successful  treatment,  but  it  also 
affords  an  understanding  of  a state  of  affairs,  which  was  very 
mysterious  when  viewed  from  the  anatomical  light  alone.  Refer- 
ence is  here  made  to  the  lack  of  correspondence  between  the 
degree  of  the  anatomical  condition  and  the  degree  of  sickness  of 
the  individual.  For  instance,  it  is  not  uncommon  to  find  infants 
with  extensive  bronchial  catarrh,  the  whole  chest  filled  with  rales 
and  often  many  of  them  quite  fine,  without  there  being  any  special 
elevation  of  temperature,  or  dyspnea  or  rapid  breathing,  or  weak- 
ness or  lack  of  interest  in  surroundings ; in  other  words,  extensive 
bronchitis  anatomically  speaking  with  but  little  sickness.  On 
the  other  hand,  slight  bronchitis  may  be  the  only  anatomical 
lesion  in  very  sick  babies.  In  neither  case  is  “bronchitis”  a suffi- 
cient diagnosis;  in  both  cases  it  is  a misleading  diagnosis.  One 
of  the  unfortunate  features  of  anatomical  diagnosis  is  its  implied 
completeness  and  its  apparent  existence  as  a distinct  entity,  a 
condition  which  very  naturally  tends  to  obscure  the  totality  of 
the  relations  existing  in  the  patient. 

But  diagnosis  to  be  complete  must  express  the  totality  of  the 
pathological  conditions  present  in  the  individual.  To  reach  this 
totality  the  pathological  state  must  be  investigated  from  the 
standpoint  df  causation.  To  secure  this  end,  the  factors  of  cau- 
sation accepted  as  fundamental  and  as  the  basis  of  clinical  inves- 
tigation, must  be  sufficient  to  comprehend  all  possible  etiological 
factors,  and  must  also  be  coordinate.  It  seems  to  me  that  all  pos- 


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sible  etiological  factors  of  pathological  processes  may  be  grouped 
under  the  four  following  coordinate  subdivisions,  viz:  Heredity, 

nutrition,  infection,  accident. 

It  will  be  seen  that  all  secondary  etiological  factors  may  be 
grouped  as  affecting  one  or  more  of  these  general  factors.  For 
instance,  age  and  sex  are  factors  affecting  nutrition,  which  is  used 
here  necessarily  in  its  most  comprehensive  sense.  Climatic  con- 
ditions influence  both  nutrition  and  infection.  Generally  speak- 
ing, accident,  or  rather  trauma,  being  purely  of  surgical  interest, 
may  be  ignored  in  any  scheme  of  medical  diagnosis.  The  influ- 
ence of  race  is  expressed  in  heredity.  The  study  of  the  heredi- 
tary conditions  is  especially  valuable  in  children,  for  in  general 
it  points  out  the  particular  dangers  ahead  of  the  individual,  and 
affords  an  opportunity  of  so  adjusting  environment  as  to  avoid 
or  postpone  these  dangers.  The  common  practice  of  ignoring 
heredity  and  relegating  its  description  to  the  indefinite  expres- 
sion, “family  history  negative/’  except  where  tuberculosis  or 
syphilis  can  be  discovered,  cannot  be  too  strongly  condemned. 
Heredity  is  never  negative.  Its  history  may  of  course  be  in- 
complete or  entirely  negative,  but  not  so  frequently  as  usually 
expressed.  When  we  find  a family  whose  members  die  at  an  ad- 
vanced age  from  cerebral  hemorrhage,  Bright’s  disease,  cardiac 
lesions,  or  other  results  of  arteriosclerosis,  we  know  that  we  are 
dealing  with  a people  whose  nutritive  processes,  determined  by 
the  special  chemical  workings  of  their  nutritive  organs,  differ 
from  those  of  the  ideally  normal  individual,  if  such  exists,  and  are 
sufficiently  peculiar  to  warrant  a special  designation  and  recog- 
nition as  of  a specific  type  of  body.  For  convenience  sake  I am 
in  the  habit  of  designating  this  type  of  nutrition  as  gouty,  without 
any  reference  to  any  of  the  theories  of  gout  extant.  When  epi- 
lepsy, insanity,  tic,  inebriety  and  other  nervous  disorders  prevail 
in  the  family,  the  agreement  I believe  is  general  to  recognize 
such  heredity  as  neurotic.  It  is  often  convenient  to  note  in  the 
heredity,  anatomical  or  functional  peculiarities  of  special  organs 
when  these  are  transmitted.  It  is  probable  that  the  elements  of 
heredity  to  be  noted  to-day  are  not  as  numerous  as  they  will 
be  hereafter,  when  a fuller  study  of  the  influence  of  heredity  upon 
the  development  and  progress  of  pathological  processes  shall 
have  led  to  more  accurate  analyses  and  the  determination  of  truer 
relations.  The  study  of  heredity  is  especially  valuable  as  afford- 
ing a clue  to  the  prevention  of  disease,  and  therefore  finds  its 
greatest  value  in  the  early  life  of  the  individual.  Indeed,  without 


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a careful  study  of  heredity  it  would  scarcely  be  possible  to  suc- 
cessfully prosecute  the  chief  aim  of  pediatrics,  viz.:  to  make  of 
a given  child  the  strongest  possible  adult. 

The  hereditary  factors  which  may  be  conveniently  noted  are 
tuberculosis,  syphilis,  gout  and  the  neurotic  type;  in  other  words 
the  conditions  often  spoken  of  as  diathetic.  As  before  remarked, 
it  is  often  convenient  to  note  anatomical  and  physiological  pecu- 
liarities of  special  organs  or  other  structures,  even  although  they 
may  be  but  particular  instances  of  the  more  general  elements 
previously  noted.  Thus  structural  defects,  like  monorchidism, 
cleft  palate,  supernumerary  fingers,  etc.,  may  be  associated  with 
epilepsy,  and  be  indicative  of  a cerebral  structural  defect.  Marked 
hepatic  disorders  in  more  than  one  generation  are  often  impor- 
tant; and  abnormalities  in  the  function  of  the  thyroid  gland  are 
of  sufficient  importance  to  always  receive  special  mention.  It  is 
clear  that  hyperthyroidation,  expressing  itself  as  Graves’  disease 
in  the  adult,  is  distinctly  transmitted  and  often  shows  itself  even  in 
the  infant.  While  subthyroidation  is  distinctly  an  infantile  dis- 
ease, I am  sure  that  in  two,  at  least,  of  my  cases  there  was  a 
distinct  heredity.  If  it  were  possible  to  determine  accurately  in 
every  case  all  the  etiological  factors  involved,  the  diagnosis  could 
be  expressed  entirely  in  terms  of  causation.  But  this  is  not  pos- 
sible, hence  many  diagnoses  must  be  expressed  tentatively  in 
terms  of  symptomatology.  Of  symptomatological  terms,  the  an- 
atomical are  usually  the  best,  but  often  functional  terms  alone 
must  be  employed,  such  for  instance  as  epilepsy  or  chorea.  More- 
over, many  anatomical  conditions  are  characterized  by  such  a 
definite  natural  history,  because  of  commonly  associated  condi- 
tions, that  their  names  are  conveniently  employed  to  designate 
such  a comprehensive  group.  Thus  for  instance,  interstitial  ne- 
phritis recalls  at  once  a very  definite  pathological  state,  but  still 
it  is  not  sufficiently  definite  because  the  elements  of  etiology  are 
entirely  ignored  in  the  term.  Certain  factors  in  the  management 
of  cases  presenting  the  condition  interstitial  nephritis  are  deter- 
mined wholly  and  solely  by  the  fact  of  this  anatomical  condition, 
while  other  factors  of  the  management  are  determined  by  the 
etiological  elements.  Hence  at  no  time  can  the  term  interstitial 
nephritis  be  considered  a complete  diagnosis.  The  anatomical 
term,  posterior  spinal  sclerosis  is  less  open  to  objection,  because 
of  its  apparent  very  close  relation  to  a predominating  etiological 
factor.  But  until  it  can  be  shown  that  the  anatomical  condition 


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is  always  the  result  of  syphilis  it  would  be  better  to  designate 
the  clinical  entity  by  the  indefinite  term  locomotor  ataxia. 

It  is,  of  course,  quite  difficult  to  keep  in  mind  these  varying 
aspects  of  disease  in  different  cases,  and  as  an  assistance  I have 
for  the  past  year  been  taking  histories  of  my  private  office  cases 
on  a form  which  shows  the  heredity,  nutritional  progress,  infection 
past  and  present,  as  well  as  the  anatomical  and  physiological  con- 
ditions. It  is  not  necessary  or  desirable  to  make  such  complete 
inquiry  into  every  case  for  which  one  is  consulted,  but  I have 
collected  in  that  time  about  300  histories  which  have  demon- 
strated to  me  very  fully  the  utility  of  the  plan.  As  an  illustration  I 
append  the  history  of  a case  in  which  I was  consulted  for  the 
purpose  of  looking  over  the  general  nutrition,  and  with  special 
reference  to  a condition  of  disturbed  sleep. 

H.  K.,  male,  age  3 years.  Family  history. — Mother,  nervous, 
active.  Maternal  grandmother,  healthy,  not  nervous.  Maternal 
grandfather  died  at  50  of  apoplexy  and  Bright’s  disease.  Father, 
strong,  active,  nervous;  has  slight  endocarditis;  is  a twin.  Paternal 
grandmother,  rheumatic,  gouty,  nervous.  Paternal  grandfather, 
age  64,  sound,  active.  No  tuberculosis  in  family;  embryonic  in- 
fluences normal. 

Nutritional  history: — Breast  exclusively  9 mos.,  and  1 mo. 
while  weaning.  Barley  water  2-3,  milk  1-3,  with  1-2  oz.  cream  in 
each  feeding  until  15  mos.,  then  occasional  egg,  potato,  oatmeal, 
orange  juice,  prunes,  bread  with  thin  butter,  bacon,  some;  cream 
and  milk  on  cereals  since  20  mos.;  animal  food,  meat,  chicken, 
etc.,  has  amounted  to  about  three  times  a week  for  the  past 
year.  No  tea,  coffee  or  other  stimulant.  Weighed  8 pounds  at 
birth  and  has  grown  normally  since.  Appetite  irregular;  always 
tendency  to  loose  bowels  but  no  putrid  diarrhea.  Dentition  nor- 
mal; walked  at  14  mos.;  talked  at  9 mos.  Has  a croupy  ten- 
dency; skin  action  below  normal;  eczema  last  winter,  lasted  4 or 
5 mos.  Has  a tendency  to  nasal  discharge;  occasional  bron- 
chitis; has  always  drooled.  First  3 mos.  severe  colic;  sleep  has 
always  been  below  normal  in  amount  and  is  much  disturbed  by 
night  terrors;  frequently  wakes  ever  hour.  Had  nocturnal 
enuresis  up  to  4 or  5 mos.  ago,  and  now  must  be  picked  up  at 
4 ten  o’clock.  Mind  very  active. 

Infection  history: — Negative,  except  broncho-pneumonia  at 
1 1 year. 

t Physical  examination: — Cranium,  thickened  in  parietal  re- 

gions. Slight  beading  of  the  ribs,  which  flare  considerably  at 


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the  edges,  forming  a marked  Harrison’s  sulcus.  Heart,  lungs,  and 
bronchial  glands  normal.  Cervical  lymphatics  shotty.  Only  one 
testicle  in  the  scrotum. 

In  this  case  the  family  history  shows  an  heredity  which  is 
gouty  and  neurotic.  The  history  of  the  feeding  indicates  a fat 
deficiency,  a conclusion  abundantly  confirmed  by  the  physical 
examination,  which  showed  quite  marked  rachitic  deformities. 

Attention  should  also  be  directed  to  the  diarrheal  tendency,  the 
croupy  tendency,  the  eczema,  the  tendency  to  mucous  catarrhs,  ? 

the  early  colic  and  the  abnormalities  of  sleep,  factors  which  showed 
that  his  gouty  heredity  was  already  affecting  his  general  nutrition 
and  making  it  necessary  to  adapt  the  nutritive  elements  of  his 
environment  to  it. 

His  infection  history  showed  that  through  this  channel  noth- 
ing had  happened  to  warp  his  organs  excepting  such  damage  as 
might  have  followed  the  broncho-pneumonia.  The  physical  ex- 
amination, revealing  normal  lungs  and  bronchial  glands,  cleared 
away  this  factor. 

The  monorchidism  did  not  influence  any  of  the  other  condi- 
tions present,  but  should  be  mentioned  in  the  diagnosis,  because 
it  might  later  in  the  history  of  this  individual  play  a role.  The 
diagnosis,  which  should  be  an  abbreviated  description  of  the  total 
physical  state  of  the  individual,  with  special  reference  to  eti- 
ological factors,  may  be  expressed  in  this  case  as  follows: 

Heredity,  gouty  and  neurotic; 

Nutrition,  fat  deficiency  and  slightly  gouty; 

Infection,  none; 

Anatomical  lesions,  monorchidism; 

physiological  abnormalities,  disturbed  sleep. 

This  diagnosis  gives  direction  to  the  management.  It  first  in- 
dicates that  the  fat  deficiency  must  be  taken  care  of;  next,  that  at- 
tention must  be  paid  to  the  gouty  elements  of  the  nutrition, 
especially  in  view  of  the  heredity;  next,  that  the  anatomical  con- 
dition may  be  ignored,  as  well  as  the  functional  abnormality, 
the  disturbed  sleep,  which  will  probably  take  care  of  itself,  when 
the  nutrition  is  corrected.  Accordingly,  Feb.  13th,  the  follow- 
ing directions  were  given:  Stop  all  red  meat,  but  allow  fowl, 

egg,  or  fish  every  other  day,  cereals,  vegetables,  dates,  figs,  pine- 
apple  juice  but  no  acid  fruits,  increase  fat,  in  the  shape  of  but- 
ter, to  the  maximum,  and  give  one  teaspoonful  of  cod  liver  oil, 
three  times  a day.  March  11,  the  following  note  was  made  , 

on  his  history:  Is  now  sleeping  quietly  from  10  p.  m.  to  6 a.  m. 


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It  might  seem  at  first  sight  as  though  considerable  unneces- 
sary effort  had  been  made  and  a needlessly  long  history  taken 
for  so  small  a matter  as  disturbed  sleep.  And  so*  indeed  it 
might  be  if  this  were  all.  But  as  a matter  of  fact  the  disturbance 
of  sleep  constituted  a highly  unimportant  factor  in  the  diagnosis 
and  really  no  part  of  the  true  diagnosis.  It  was  merely  one  of 
the  indices  of  the  true  conditions.  The  real  factors  of  the  case 
I were  the  fat  deficiency  and  the  autotoxemia.  The  removal  of  the 

first  of  these  and  the  control  of  the  second  could  not  fail  to  in- 
fluence the  child’s  general  nutrition,  and,  as  general  prophylactic 
I procedures,  were  highly  important. 

The  diagnosis  is  not  expressed  in  one  word  for  the  very  ex- 
cellent reason  that  there  is  no  one  word  which  covers  the  condi- 
tions. 

The  insufficiencies,  inconveniences  and  untruthfulness  of 
single  terms  to  express  diagnosis,  have  long  been  felt,  and  so  the 
terms,  complications,  and  sequelae  have  been  utilized  to  help 
avoid  the  difficulties. 

If  diagnoses,  expressed  in  the  manner  which  I am  here  ad- 
vocating are  cumbrous,  they  are  so  because  the  conditions  which 
they  describe  are  complex. 

Four  distinct  advantages  follow  the  use  of  this  method  of  de- 
termining and  expressing  diagnosis: 

ist.  The  totality  of  the  conditions,  determinable  by  our  pres- 
ent methods  of  clinical  examination,  are  fully  set  forth. 

2(1.  The  indeterminate  factors  are  thrown  into  strong  relief, 
placed  where  they  cannot  escape  attention  and  their  general  re- 
lations established. 

3d.  By  bringing  clearly  forward  the  indeterminate  elements 
of  diagnosis  there  are  suggested,  and  pointed  out  lines  of  clinical 
observation  which  are  likely  to  be  useful. 

4th.  The  absolute  certainty  of  opinion  which  is  apt  to  accom- 
pany single  term  diagnosis,  is  prevented,  a state  of  affairs  useful 
to  the  patient,  even  if  not  altogether  conducive  to  the  physician’s 
self-esteem. 

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408  Center  Street. 


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